A nurse is providing teaching to a client following surgery to repair a detached retina of the left eye. Which of the following instructions should the nurse include in the teaching?
Avoid reading for 3 months.
Pick up items by bending at the waist.
You can lift objects that weigh up to 50 pounds.
Take a stool softener daily.
The Correct Answer is D
Choice A reason: Avoiding reading for 3 months is not a standard instruction post-retinal detachment surgery. Reading may be restricted temporarily (e.g., 1-2 weeks) if specific positioning is required, but 3 months is excessive. Patients are typically advised to avoid straining, not reading, making this instruction incorrect.
Choice B reason: Bending at the waist increases intraocular pressure, which can disrupt retinal repair and lead to re-detachment. Patients should bend at the knees to avoid straining the eye. This instruction is harmful and contraindicated, as it risks complications in the healing retina.
Choice C reason: Lifting objects up to 50 pounds is dangerous post-retinal surgery, as heavy lifting increases intraocular pressure, risking re-detachment. Guidelines typically restrict lifting to 10-20 pounds during recovery (4-6 weeks). This instruction is incorrect, as it poses a significant risk to surgical outcomes.
Choice D reason: Taking a stool softener daily prevents straining during bowel movements, which can increase intraocular pressure and disrupt retinal healing. Constipation is a concern post-surgery due to immobility or pain medications, and stool softeners ensure safe bowel movements, making this the correct instruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Performing postural drainage immediately after meals risks aspiration and discomfort due to gastric contents shifting during positioning. It should be done 1-2 hours after meals to ensure safety and efficacy in clearing mucus from the lungs, making this timing inappropriate for cystic fibrosis management.
Choice B reason: Performing postural drainage twice daily is recommended for cystic fibrosis to mobilize thick mucus from the lungs, improving airway clearance and reducing infection risk. This frequency balances effectiveness with patient tolerance, aligning with evidence-based guidelines for managing chronic respiratory conditions, making it the correct action.
Choice C reason: Using a percussion vest is an alternative to manual postural drainage but is not specified as the only method. Manual techniques are effective and standard unless a vest is prescribed. This choice assumes equipment availability, which may not apply, making it less universally appropriate than scheduled manual drainage.
Choice D reason: Positioning the child flat during postural drainage is incorrect, as specific angled positions (e.g., head-down) are needed to target lung segments and promote mucus drainage by gravity. Flat positioning reduces effectiveness and may not clear airways adequately, making this an inappropriate technique for cystic fibrosis.
Correct Answer is A
Explanation
Choice A reason: Calcium gluconate IV reverses magnesium sulfate toxicity, which causes respiratory depression or arrhythmias due to excessive magnesium. Calcium restores neuromuscular and cardiac function by competing with magnesium, preventing life-threatening complications like respiratory arrest in preeclampsia management.
Choice B reason: Positioning supine is inappropriate, as it does not address magnesium toxicity and may worsen respiration in preeclampsia. Semi-Fowler’s position optimizes breathing, while toxicity requires pharmacological reversal with calcium gluconate, not positional changes, to manage life-threatening symptoms effectively.
Choice C reason: IV dextrose is irrelevant for magnesium toxicity, which affects neuromuscular function, not glucose levels. Dextrose treats hypoglycemia, not applicable here. Magnesium overdose requires calcium to counteract effects, making dextrose an ineffective intervention in preeclampsia-related toxicity management.
Choice D reason: Methylergonovine, a uterotonic, is contraindicated in preeclampsia, as it increases blood pressure, risking hypertensive crisis. It treats postpartum hemorrhage, not magnesium toxicity, which requires calcium gluconate to reverse neuromuscular depression, ensuring safety in preeclampsia management.
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